Who’s at the Center of Your Practice – You or Your Patient?

Harvey Abrams PhD

“Peeling the Onion” is a monthly column by Harvey Abrams, PhD. 

To date, “Peeling the Onion” has focused on a rehabilitative approach to audiologic treatment to include such concepts as the Health Belief and Transtheoretical (Stages of Change) models. The primary objective (and, many would say, the compelling advantage) of the rehabilitative approach is to better understand the needs of the patient from his or her perspective rather than the nature of the disorder, as is often the focus of the Medical Model approach.

Are Audiologists Practicing Patient-Centered Care?

Understanding hearing loss from the patient’s perspective allows us to better explore their motivation for seeking care and their current “location” on the patient journey, as well as to include them in the decision-making process in order to optimize patient compliance and optimize treatment results. This idea of including the patient in the management process is the driving principle behind “Patient-Centered Care” (PCC) (Figure 1).

Figure 1. The patient-centered care model.

As described by the Agency for Healthcare Research and Quality :

“In a patient-centered model, patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals.”

One would assume that most audiologists when asked (and I have asked many audiologists on many occasions) would agree (indeed, insist) that they practice “patient-centered care.”  However, when their behaviors are explored systematically, it becomes clear that most clinicians violate many of the basic tenets of PCC.  Specifically, audiologists tend to

• monopolize the conversation,
• ask closed-end (“yes” or “no”) questions,
• attempt to get through a checklist  of procedures within a strict time limit,
• provide information to the patient that may not necessarily be meaningful,
• use audiologic jargon that is often incomprehensible to the patient,
• fail to confirm that the patient understands the information being delivered,
• neglect to include family members, and
• make treatment decisions on the basis of test results rather than on the expressed needs of the patient and family members.

Not According to the Evidence

One of the leading audiology researchers in the area of PCC is Caitlin Grenness of the University of Melbourne. Her studies have furthered our understanding of PCC and its application to audiologic rehabilitation.  One particularly revealing study by Grenness and colleagues{{1}}[[1]]Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2014). Communication Patterns in audiologic rehabilitation history-taking: audiologists, patients, and their companions. Ear Hear, 36(2), 191–204.[[1]] involved a series of video-recordings of provider-patient interactions during the history-taking phase of the consultation followed by coding and analysis or those interactions. This particular phase of the consultation lasted just under 9 minutes during which a companion was involved an average of 27% of the time.

For most of the interview process, audiologists asked 97% of the questions (primarily in a closed-set format) and interrupted the patient, on average, after 21 seconds – hardly a PCC approach.

In a related study by Grenness and colleagues{{2}}[[2]]Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2015). The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations. JAAA 26, 36-50.[[2]] concerning the diagnosis and management planning phase of the clinical encounter, the researchers determined that hearing aids were recommended an average of 83% of the time, while scant attention was paid to alternative treatment strategies or to involving the patient or the patient’s communication partner in the management planning process. The clinicians missed important opportunities to explore the psychosocial consequences of hearing loss from the patient’s/companion’s perspectives.  Perhaps, not surprisingly,

only 56% of the patients observed in this study for whom hearing aids were recommended elected to obtain them.

Excellent Resources are Available

For an excellent review of the literature on rehabilitative audiology and PCC, the reader is referred to an article by Grenness and colleagues in a 2014 supplement to the International Journal of Audiology{{3}}[[3]]Grenness, C., Hickson, L., Laplante-Lévesque, A., & Davidson, B. (2014). Patient-centred care: a review for rehabilitative audiologists. Int J Audiol, 53, Suppl 1, S60-7.[[3]] An abstract of that article can be found here.  An excellent resource for better understanding audiologic-specific PCC, to include articles, tools, and interviews can be found at the Ida Institute.

This is not the first post in which I have referred to the Ida Institute, and this is by design. The Ida Institute is charged with fostering “a better understanding of the human dynamics associated with hearing loss.” In other words, its mission is all about the non-technology aspect of audiologic intervention, including PCC.  The website is a rich source of information, including clinician-ready tools for assessing patient motivation, involving communication partners, and self-development.

This is Part 6 of the Peeling the Onion series.  Click here for Part 1, Part 2,  Part 3,  Part 4, Part 5, or Part 7.

Harvey Abrams, PhD, is Principal Research Audiologist at Starkey Technologies. Dr. Abrams has served in various clinical, research, and administrative capacities with Starkey, the Department of Veterans Affairs and the Department of Defense. Dr. Abrams received his master’s and doctoral degrees from the University of Florida. His research has focused on treatment efficacy and improved quality of life associated with audiologic intervention. He has authored and co-authored several recent papers and book chapters and frequently lectures on post-fitting audiologic rehabilitation, outcome measures, health-related quality of life, and evidence-based audiologic practice.  Dr. Abrams can be reached at [email protected]